Data Management

Section I: Investigator Information
Date Data is Needed  
PI Name  
PI Title  
PI Contact Number  
Email Address  
Campus Mail Code  
Affiliation
  
Names/Titles/Affiliations of investigators involved in this research study

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Are you an IU CHSOR/CIEBP Core Investigator?    Yes No
Are you working with an IU CHSOR/CIEBP Core Investigator?    Yes No
If Yes, who?
Section II: Study Information
Study Title  
Study Hypothesis/AIM of Study  

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Inclusion Criteria (include time frames, specific codes (ICD-9, CPT), laboratory values, etc. that define the inclusion criteria) 

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Exclusion Criteria (include time frames, specific codes (ICD-9, CPT), laboratory values, etc. that define the exclusion criteria) 

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Variables of Interest (dependant variable/outcomes measures/confounders) 

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Requested Date Range of Data (Data is available from January 1, 1997 to 2-months prior to the current date)
 
Type of Data Requested (e.g., local data, national data, multi-site)
 

 

Section III: Study Funding/Grant Information
Part A: Preliminary Data Request
Are you planning on using the preliminary data to apply for a grant?    Yes No
Grant Deadline  
Name of potential funding/grant agency and type of award
 
Why preliminary data is required
 
Part B: Data Request for Funded Study
Funding source  
Grant Number  
Dates for Funding  
The investigator is using the data for a research project    Yes No
If data are to be used for research:
  Copies of the IRB approval letter, Summary Safeguard Statement, VA R&D Approval, and approved research protocol have been provided and are on file in the Research Office (Room D3040) of the Roudebush VA Medical Center
  The investigator's description of the intended use of the data in the approved research protocol agrees with the description on the Summary Safeguard Statement
  Upon completion of this study, the provided patient-specific data will be destroyed per State law at the required time or returned to the IU CHSOR/CIEBP Data Program Mananger for storage until such stated time that data can be destroyed
Part C: Quality Improvement Data Request
Purpose of the data request

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Part D: Data Request for Publications
The investigator is using the data for publications    Yes No
If data are to be used for publications:
  Copies of the IRB approval letter, Summary Safeguard Statement, VA R&D Approval, and approved research protocol have been provided and are on file.
  The investigator's description of the intended use of the data in the approved research protocol agrees with the description on the Summary Safeguard Statement
  Upon completion of this study, provided patient-specific data will be destroyed or returned to the Data Program Manager
Principal Investigator Name
 
Date  
Accept